Palliative Medicine: the basics

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Palliative Medicine the basics

• Tara Tucker MD FRCPC
• Lisa Aldridge MD CCFP

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Objectives

• Definition of Palliative Care
• The Role of Palliative Medicine
• Pain
• Constipation
• Nausea
• Dyspnea
• ETHICS

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Palliative Care

• "an approach that improves the quality of life of
  patients and their families facing the problems
  associated with life-threatening illness." WHO
• palliative treatments may be used to alleviate
  the side effects of curative treatments, such as
  relieving nausea

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1967 Dame Cicely Saunders opens St.
Christophers Hospice
                                             
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1995, first stand alone paediatric hospice in
N.A., Canuck Place, Vancouver
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Dr. Bohen will be out here to talk to you in
just a minute All I can tell you is that your
husbands condition has stabilized!
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• We will all face death in our lives and in our
  work.
• 10 of us will die suddenly. but what about the
  rest?

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End of Life Care

• Most of us in this room will DO and NEED
  palliative care
• 220 000 Canadians die each year
• Process and outcome has tremendous effect on
  others collateral suffering
• Only 5 people receive integrated,
  multidisciplinary palliative care
• Cancer patients (25 deaths) receive 90
  palliative care
• Pain and symptoms are poorly controlled

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Medicines Shift in Focus

• Many health care providers feel they have
  failed if the patient dies our own fear of death
  may influence how we approach others

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• To cure sometimes
• To relieve often
• To comfort always
• Socrates

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Where does Palliative Care fit in?

Disease-focused care
Death
Comfort-focused care F/up
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The Dying PatientYour Role

• Relieve suffering
• Provide Comfort and compassion to both the
  patient and the family

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Formulate a Plan for the Dying Patient

• Pain Control
• Maintain human dignity
• Avoid isolation of patient
• Discuss with patients their wishes or refer to
  advance directive
• Provide emotional and spiritual support

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Advance Care Planning

• Process of making decisions about future medical
  care with the help of health care providers,
  family and loved ones
• Discuss diagnosis, prognosis, expected course of
  illness, treatment alternatives, risks, benefits
• In context of patients goals, expectations,
  values, beliefs and fears

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EOL Decision Making

• People need time to reflect on goals, values,
  beliefs
• EOL decision making is a process, not a one time
  event
• Multidisciplinary team to convey info, discuss
  alternatives, provide emotional and psychological
  support avoid mixed messages

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What you need, Mr. Terwilliger, is a bit of
human caring a gentle, reassuring touch a warm
smile that shows concern--all of which, Im
afraid, were not a part of my medical training.
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Communication

• Talk about death find the words
• Hope for the best, plan for the worst
• Lose the medical jargon
• Being, not doing
• Compassion/presence and balance
• Cultural sensitivity
• Collaboration with team members

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Phrases to Avoid

• It doesnt look good
• Too vague, be more specific
• Do you want us to do everything?
• We will not do anything extraordinary, heroic,
  or aggressive.
• Implies substandard care
• Theres nothing more that we can do.
• Implies abandonment

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Language to describe the goals of care

• We want to give the best care possible until the
  day you die.
• We will concentrate on improving the quality of
  your childs life.
• We want to help you live meaningfully in the time
  that you have.

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language to describe the goals of care

• I will focus my efforts on treating your
  symptoms.
• Lets discuss what we can do to fulfill your wish
  to stay at home.

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Withholding or Withdrawing Treatment

• What does the pt/family know and understand about
  life sustaining Rx ie risks and benefits
• What are the goals of care/ pts wishes
• Explain how it will be done and what to expect
• How will pain/distress be managed
• Pertinent religious/cultural issues
• Time limited trials for some interventions ie
  dialysis

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I wish youd called me sooner, Mrs. Moodie.
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When to call on Palliative Medicine Specialist?

• Early in the trajectory of life limiting illness
  again, find the words to use
• When major decisions have to made re treatment
• When symptom management is problematic

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Pain

• an unpleasant sensory or emotional experience
  associated with actual or potential tissue
  damage, or described in terms of such damage
• World Health Organization

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Pain

• a state of distress associated with events that
  threaten the intactness of a person
• Eric J Cassell. The Nature of Suffering and
  the Goals of Medicine. NEJM 1982 306
  639-645

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Pain

• Chronic pain serves no physiologic purpose
• Under-treated pain may lead to depression and
  suicide

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Total Pain Pie
physical
emotional
e.g. arthritis, bowel spasms, headache caused by
CVA
e.g. depression, anxiety, loss of control
social
spiritual
Loss of role, loss of social contacts
- search for meaning
Lili/presentations/1999/pie.ppt
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Causes of Cancer Pain

• Direct effects of the disease
• Related to disease ie constipation
• Secondary to treatment 20
• Surgery
• Chemotherapy
• Radiation

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Physiological Pain Categories

• Nociceptive localised
• Somatic superficial, deep
• Bone mets, cellulitis
• Visceral
• Infiltration, compression, distension of viscera
• Neuropathic may radiate along dermatome, nerve
  distribution
• TGN, herpes zoster

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Neuropathic Pain

• Sympathetic
• Central
• Peripheral (non-sympathetic)

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Neuropathic Pain

• Spontaneous pain
• Dysesthesia
• e.g. burning
• Neuralgia
• e.g. lancinating, electric shocks
• Evoked pain
• Allodynia
• Pain from a non-painful stimulus
• Hyperalgesia
• Pain more than expected from a mildly painful
  stimulus
• Hyperpathia
• Explosive build-up of pain with repetitive stimuli

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Evaluating Pain

• Believe the patient
• Initiate discussions
• Detailed pain history
• Careful physical exam
• Investigations
• Monitor results of treatment

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Pain History the key!

• P provokes and palliates
• Q quality
• R Radiates - location
• S severity
• T time duration, time of day
• O other ie red flags
• Headache vomiting

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Principles of Analgesic Therapy

• By the mouth
• By the clock
• By the ladder
• For the individual
• Attention to detail

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• The ideal treatment for any pain is to remove
  the cause.

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Treating Pain

• Use a Multidisciplinary approach
• Medications
• Counselling
• Physical Therapy
• Nerve block
• Surgery

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WHO Pain Ladder
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WHO Pain Ladder
3 Severe
Morphine Hydromorphone Methadone Fentanyl Oxycodon
e Acetaminophen NSAIDs Adjuvants
2 Moderate
Acetaminophen Codeine Acetaminophen
Oxycodone NSAIDs Adjuvants
1 Mild
Acetaminophen NSAIDs Adjuvants
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NSAIDS

• Antiinflammatory
• Adverse effects
• Gastropathy, renal failure, platelet inhibition,
  cardiac
• Risk factors
• Age, PUD, cachexia, dehydration, steroids,
  comorbid conditions

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Combination medications

• Percocet (oxycodone and tylenol)
• Tylenol 3 (Codeine and tylenol)
• Limited by dose of acetaminophen

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Opioidschoosing the right drug

• Morphine is first line
• Morphine metabolites will accumulate in renal
  failure patients suggest fentanyl or
  hydromorphone
• Do NOT use meperidine (Demerol) due to
  metabolites causing adverse effects

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Opioids choosing the right drug

• Pts previous experience with opioids
• Compliance
• Fears and myths pt MD!
• Physician comfort experience

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Opioids choosing the right dose

• Opioid naïve patient
• Morphine 2.5 - 5 10 mg po q4h
• Hydomorphone 0.5 1 mg po q4h
• Oxycodone 2.5 - 5 mg po q4h
• Percocet
• Some references give higher starting doses
  CAUTION!

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Opioids choosing the right schedule

• Immediate Release (IR)
• Q4h dosing straight
• Prn q1-2h at 10 of daily dose
• Sustained release (the Contins)
• Q12h, prn IR 10 daily dose

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Opioids adverse events

• Common
• Constipation is easier to prevent than treat
• Softener laxative
• Nausea (tolerance develops)
• Maxeran, Haldol
• Sedation (tolerance develops)
• Dry mouth

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Opioids - Adverse events

• Less common
• Urinary retention
• Pruritis
• Delirium
• Myoclonus
• Psychotomimetic effects
• Postural hypotension
• Vertigo

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Opioids adverse events

• Rare
• Allergy
• Codeine allergy most common, unlikely
  cross-reactivity with other opioids
• Respiratory depression

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Fentanyl Patch

• See table for equianalgesic doses
• For stable pain
• Dosage increases in 2-3 day intervals
• Careful in opioid naïve patients!
• 25 mcg/hr 90 mg/d morphine 18 mg/d
  hydromorphone

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Withdrawal

• Tachycardia, hypertension, diaphoresis,
  pilo-erection, N, V, diarrhea, body aches, abdo
  pain, psychosis, hallucinations

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Opioids and Tolerance

• Characterized by decreased efficacy and duration
  of action with prolonged repeated use of the drug
• Need for higher doses to maintain same level of
  analgesia
• Normal pharmacological response

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Opioids and Psychological Dependence

• Addiction
• Characterized by craving for the drug and a
  preoccupation for it
• Rarely occurs in cancer patients
• Beware of labeling a patient who actually has
  uncontrolled pain
• Screening for addiction potential (CAGE)

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I hate to tell you this, but Ive still got the
headache.
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Anti-convulsants

• Carbamazepine
• Block Sodium channels
• Reduce hyperexcitability
• Gabapentin
• Action unclear, ? Ca channels
• SE dizziness, sedation

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Tri-cyclic antidepressants

• Nortriptylline 10 mg po qHS
• Inhibit serotonin and NE reuptake
• Block Sodium channels
• SE dry mouth, sedation, hypotension

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Constipation

• Debility
• Decreased fluids and food
• Metabolic hypothyroid, hypokalemia,
  hypercalcemia
• DRUGS
• Autonomic dysfunction DM, CA, SCC
• Obstruction

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DRUGS

• Anticholinergics ex TCAs
• Antacids
• Iron
• Zofran
• Diuretics
• Anticonvulsants
• NSAIDS
• Chemotherapy

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OPIOIDS

• Increase Bowel tone
• Decrease pancreatic and biliary secretions
• Delay Gastric emptying
• Decrease peristalsis
• Increase transit time
• Decrease the urge to defecate

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Managing Constipation

• PRIVACY
• Increase fluids and activity
• R/O obstruction, with an Xray if necessary
• All patients starting on Opioids need laxatives

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Suggested Laxative Regime
Start Stimulant Senokot 2-4 tabs po qhs
and Softener Colace 200mg po daily If needed
add Osmotic agent Lactulose 30 cc po BID prn or
M of M 60 mls/ day If needed Rectal agents
Bisocodyl supp and/ or Fleet enema
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• Warning
• Fiber no water cement

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DELIRIUM Common and under-recognized

• A Disturbance in consciousness
• Characterized by
• decreased attention, acute onset fluctuation

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Causes of Delirium

• Metabolic Hypoxemia, Hypoglycemia, Hypothyroid,
  Thiamine defn
• Electrolyte AbN High Na, Ca, or Mg
• Drugs and toxins opioids, anticholinergics,
  withdrawal
• Organ failure RF, Liver, CHF, CO2, sepsis
• Brain tumor, infection, vascular events, seizures

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Management

• Determine WHO is at risk
• Screen with MMSE
• Find underlying cause
• Obtain collateral history

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Consent when delirious

• You may use substituted judgment if you
  know the patient well
• Use a substitute-decision maker otherwise
• Treat without consent if in an emergency

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Treatment for Delirium

• Haldol or atypical antipsychotic (olanzapine,
  risperidone)
• NO Ativan

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Causes of Nausea

• GI gerd, motility, tumor, gastritis, obstruction
• BRAIN High ICP, tumor, anxiety
• EAR Vestibular disturbances
• DRUGS
• SYSTEMIC infection, toxins, uremia
• CANCER paraneoplastic syndromes, ov ca

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Treatment mechanistic approach

• Drugs, toxins, metabolic (CRTZ)
• Anti-dopaminergic maxeran, haldol
• Vestibular
• anticholinergic, antihistamines
• Chemo/radiation - ondansetron

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Dyspnea

• Treat the cause
• O2 if helpful or hypoxic
• Opioids

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Double Effect

• Appropriate treatment of pain is morally
  acceptable even if it hastens death as long as
  there was no intention to do so.

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Physician Assisted Suicide

• The physician supplies the patient with the
  means, usually medication, to end their life. Not
  legal in Canada.

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Euthanasia

• The physician administers a medication with the
  intent of causing death. Also not legal in Canada.

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• Speak gently, treat aggressively

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SAVE the patient you idiot!! I said weve got
to do whatever we can to SAVE the patient!!